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342 Journal of the American Academy of Orthopaedic Surgeons
Orthopaedic surgeons increasingly
are facing situations that require soft-
tissue coverage of lower-extremity
defects. Severe open tibial fractures
often require coverage of exposed
bone fragments with well-vascular-
ized tissue, thereby preserving bone
viability and reducing the potential
for osteomyelitis. After total knee
arthroplasty, wound-healing prob-
lems may be successfully treated
with gastrocnemius flaps. Limb-pre-
serving oncologic surgery presents
opportunities for creative flaps.
However, procedures to gain soft-tis-
sue coverage in these and other situ-
ations are often referred to surgeons
who have more training and experi-
ence with such procedures.
In the 25 years since Ger
1
popular-
ized local muscle flaps to cover soft-
tissue defects over the anterior tibia,
a multitude of other local and free
flaps have been described and per-
fected. Complex local flaps and free
flaps have greatly expanded limb-
salvage indications. Some bone and
soft-tissue defects can now be suc-

cessfully treated with the bone and
soft-tissue transport techniques ini-
tially popularized by Ilizarov.
Some lower-extremity local flaps
offer predictable results and are rel-
atively easy to perform. They are not
applicable in all situations, and the
indications and limitations of each
flap must be clearly understood.
This review will describe five lower-
extremity local flaps that, in our
opinion, can be used effectively by
orthopaedic surgeons. These flaps
were chosen for description because
of the relative ease of surgery, relia-
bility, and minimal donor-site mor-
bidity. However, they are not useful
in the region above the ankle and on
many areas on the foot. While the
dorsalis pedis island flap can be uti-
lized in the repair of defects around
the ankle, there are many technical
pitfalls in its use. Use of a free flap
or complex local flap is often neces-
sary on the distal part of the lower
extremity.
General Considerations
Flaps are named for the types of tis-
sue moved. A muscle flap moves
only muscle and often requires a

skin graft on the transposed muscle
to complete closure of the defect. A
musculocutaneous flap transports
muscle and skin. The more recently
described fasciocutaneous flaps uti-
lize the blood supply to the fascia,
usually near a deep intermuscular
septum, to increase the blood supply
to the skin being transported. Direct
cutaneous, or axial-pattern, flaps uti-
lize subcutaneous arteries and veins
in specific body sites to transport
Lower-Extremity Local Flaps
Gary D. Bos, MD, and Mark J. Buehler, MD
Dr. Bos is Associate Professor of Surgery
(Orthopaedics), University of North Carolina
School of Medicine, Chapel Hill. Dr. Buehler is
Assistant Clinical Professor of Surgery
(Orthopaedics), Oregon Health Sciences Univer-
sity, Portland, and Hand Surgeon, Emanuel
Hospital and Medical Center, Portland.
Reprint requests: Dr. Bos, Department of
Surgery (Orthopaedics), University of North
Carolina School of Medicine, Chapel Hill, NC
27599-7055.
Copyright 1994 by the American Academy of
Orthopaedic Surgeons.
Abstract
Some soft-tissue defects of the lower extremities can be covered reliably with local
flaps. Five such flaps—-the tensor fascia lata, gastrocnemius, soleus, posterior tib-

ial artery fasciocutaneous, and dorsalis pedis flaps—-are described. If the indica-
tions for each flap are understood and the vascular pedicle is carefully preserved,
these flaps can be used to provide relatively simple and reliable coverage of selected
soft-tissue defects on the lower extremities. However, the indications must not be
overextended in an attempt to avoid a free-tissue transfer. The gastrocnemius flap
is most often used. It reliably covers common defects about the knee and the prox-
imal tibia. A skin graft is required for the gastrocnemius flap, as well as the soleus
flap, which covers the midportion of the tibia. The soleus requires deeper dissec-
tion of the calf for elevation. The tensor fascia lata flap and the more recently
described posterior tibial artery fasciocutaneous flap are relatively easy to raise,
but there are fewer orthopaedic indications for their use. The dorsalis pedis cuta-
neous flap is technically more demanding, but it can be used to cover difficult
defects around the ankle.
J Am Acad Orthop Surg 1994;2:342-351
only cutaneous tissue. A flap trans-
porting skin may require a split-
thickness skin graft at the donor site
for closure. Alterations in the con-
tour of the donor site or in the recip-
ient bed may lead to an unacceptable
cosmetic result. This is particularly
true in the thighs of heavy women
where cosmetic flap revision may be
required at a later date.
Mathes and Nahai
2
have provided
a useful classification of muscle flaps,
although the principles of the classi-
fication are often applied to other

types of flaps. A type I flap has a sin-
gle vascular pedicle and is easiest to
transfer. The tensor fascia lata (TFL)
and gastrocnemius muscle flaps are
examples. The type II flap has one or
more dominant pedicles, as well as
minor pedicles on the distal end of
the muscle, which must be severed to
rotate the flap. Occasionally there
are problems with vascularity at the
end of the flap distant from the major
pedicle. Type III (two major pedi-
cles), type IV (segmental pedicles),
and type V (one dominant and mul-
tiple secondary pedicles) flaps have
more complex vascular patterns and
are not included in this review.
This classification points out the
necessity of always being aware of
the vascular supply of the tissue to be
moved. Separation of the major vas-
cular pedicle dooms the transfer, as
does excessive tension or twisting of
the pedicle. When the flap is used for
coverage, preservation of the neuro-
logic pedicle is unnecessary.
3
In fact,
preservation of the neurologic pedi-
cle may lead to delayed healing of a

skin graft due to movement in the
flap. Abnormal sensations may be
present, although this has not been a
major problem in our experience.
When a flap is used to provide cov-
erage for an area of insensate broken-
down skin, neurologic pedicle
preservation may be beneficial, but is
beyond the scope of this review.
Local flaps rotate about their vas-
cular pedicle and not about the ori-
gin of the muscle. This characteristic
may be used to advantage; for exam-
ple, in the gastrocnemius muscle, the
origin can be detached from the
femur to gain more length. How-
ever, the surgeon must always be
careful to avoid overestimating the
ability of the flap to cover a defect.
The vascular pedicle must be kept in
mind as the flap is elevated to avoid
tension or even disruption of the
vessels and failure of the flap.
The availability of local flaps is often
influenced by associated trauma, par-
ticularly in the area of the flap.
Crushed tissue or tissue with avulsed
or traumatized pedicles will not sur-
vive rotation. A preoperative arteri-
ogram may be required to document

adequate circulation in situations with
trauma or previous surgery near the
tissue to be transferred. Nearby
trauma is especially harmful to fascio-
cutaneous flaps that have multiple
small perforating vessels through the
fascia into the skin. Avulsion of these
small vessels during surgery may be
prevented by placing temporary
sutures at the edge of the flap to hold
subcutaneous tissues to the fascia
while the flap is being manipulated.
Care must also be taken to avoid vas-
cular compromise of tissues near the
donor site, as in the case of the tunnel
under the skin commonly used with
gastrocnemius transfer. The area of
undamaged skin over a tunnel should
be at least 7 cm wide to avoid vascular
compromise. Whenever possible,
veins should be preserved with the
transferred tissue to avoid vascular
congestion in the flap. With the excep-
tion of the dorsalis pedis island flap,
we do not feel that preoperative vas-
cular studies are necessary for the
flaps described unless there is associ-
ated trauma, as noted above.
Tensor Fascia Lata
Musculocutaneous Flap

The TFL musculocutaneous flap is a
type I flap consisting of the TFL mus-
cle, the fascia lata tendon, and the
overlying skin.
4
The pedicle for this
flap is the ascending branch of the lat-
eral femoral circumflex artery and
vein. The flap can be used to cover
groin, ischial, trochanteric, and thigh
deficits on the lower extremity (Fig. 1).
There are many advantages to this
flap. It has a reliable blood supply
and can be raised easily as a pedicle
flap. Potentially, one can raise a large
flap extending superiorly from the
anterior superior iliac spine to 10 cm
above the knee and from the midline
anteriorly to the midline posteriorly.
However, most flaps are smaller and
do not extend closer than 15 cm
above the knee. The TFL functions as
an accessory hip flexor, hip abductor,
and internal rotator of the thigh. It is
not the primary muscle for any of
these functions, making it function-
ally expendable. A sensory myocu-
taneous flap can be constructed if the
limitations in size described by
Strauch and Yu

5
are followed. The
sensory TFL flap is not described in
this review.
Vol 2, No 6, Nov/Dec 1994 343
Gary D. Bos, MD, and Mark J. Buehler, MD
Fig. 1 Potential areas of coverage available
with the TFL flap. The end of the flap can be
as close as 10 cm, but is preferably 15 cm,
from the knee-joint line.
There are some disadvantages
with this pedicle flap. The sec-
ondary defect in the thigh may not
close primarily if the width of the
TFL flap exceeds 6 cm in a patient
with normal habitus. Therefore, a
split-thickness skin graft will be
required for closure. In the thin male
patient this is not a major cosmetic
problem, but in a woman with heavy
thighs a significant contour defect
results. In addition, in heavy
patients the thickness of the flap may
necessitate later surgery to recon-
tour and thin the transported flap.
Another disadvantage results
from the fascia lata itself, which
comprises the undersurface of the
distal half of the flap. This fascia is
stiff and does not fold well over con-

cave surfaces or tuck well into deep
holes. Also, the fascia lata does not
adhere well to the underlying defect,
and in contaminated wounds the
potential dead space between the
flap and the wound can be a source
of hematoma or abscess. In patients
with surgical scars in this area, this
flap should not be attempted unless
an arteriogram documents patency
of the pedicle, because the vascular
pedicle to the flap is often severed in
the routine anterior or anterolateral
surgical approach to the hip.
Anatomy
The TFL muscle arises from the
ilium between the origin of the glu-
teus minimus and the anterior part
of the iliac crest.
6
The muscle lies
between the laminae of the iliotibial
tract and inserts into the tract just
below the level of the greater
trochanter. The muscle is about 5 cm
wide. Its posterior border runs from
a point 5 cm posterior to the anterior
superior iliac spine down to the ilio-
tibial tract, passing just anterior to
the greater trochanter. The surface

marking of the muscle is easily
demonstrated by having the supine
patient elevate the leg with the knee
extended. The muscle stands out
readily, and the axis of any proposed
flap should be marked preopera-
tively along the course of the
demonstrated muscle.
The arterial supply is from the
ascending branch of the lateral femoral
circumflex artery, which is usually a
branch of the deep femoral artery. This
2-mm-diameter vessel passes laterally
deep to the sartorius and rectus
femoris muscles, under which it
divides into ascending and descend-
ing branches. The ascending branch
courses along the intertrochanteric line
at the site of origin of the vastus inter-
medius and lateralis muscles under
cover of the rectus femoris. Here it
enters the TFL muscle on its deep sur-
face at the level of the greater
trochanter (Fig. 2).
Flap Elevation
The flap usually measures 8 to 12
cm in width and is always centered
over the muscle with the upper bor-
der being the iliac crest. Flaps can be
raised to a length of about 30 cm or

to within 10 cm, but preferably 15
cm, from the knee joint. Usually the
cutaneous anterior boundary of the
TFL flap is defined by a line from the
anterior superior iliac spine to the
lateral femoral condyle, but it can
extend as far as the midline of the
thigh. The posterior border follows
a line from the posterior edge of the
greater trochanter to the center of the
lateral femoral condyle, although a
wider flap extending to the edge of
the biceps femoris muscle can be
designed.
The dissection is started inferiorly
with an incision through the skin
and fascia onto the vastus lateralis
muscle. The fascia is sutured to the
skin to avoid shearing of the skin
from the underlying fascia. The
anterior and posterior margins are
incised, and the flap is elevated from
distal to proximal by using blunt fin-
ger dissection to gently separate the
fascia from the underlying vastus
lateralis. The posterior incision can
be safely extended to the iliac crest to
help mobilize the flap, since the
pedicle enters on the anterior bor-
der. Proximally, the anterior inci-

sion should stop about 10 cm below
the anterior superior iliac spine, as
this is where the vascular pedicle is
located (Fig. 2). Exposure of the
pedicle is not necessary unless a
greater degree of mobilization is
needed for flap transposition.
The flap is then transposed to
cover the defect. The sutures
placed previously to avoid shear-
ing are removed, and the flap is
sutured in place. During transposi-
tion and insetting, the color of the
flap and bleeding from the edge of
the flap must be watched closely.
The pedicle can become kinked,
leading to insufficient arterial
inflow manifested by pale color or
lack of bleeding. Occlusion of the
344 Journal of the American Academy of Orthopaedic Surgeons
Lower-Extremity Local Flaps
Fig. 2 Outline of a typical TFL flap. A
wider flap would necessitate a skin graft for
closure of the donor site. The TFL muscle
area is shaded.
draining veins may make the flap
appear dark and congested with
excess bleeding. In either case, the
flap must be taken down immedi-
ately, and the pedicle must be

explored and mobilized to restore
patency. The donor site is closed
primarily if possible, or a split-
thickness skin graft is applied.
Gastrocnemius Muscle Flap
Skin-grafted medial or lateral gas-
trocnemius muscle flaps are the
workhorse local transposition flaps
for soft-tissue coverage of the knee
and the proximal third of the tibia
(Fig. 3).
7
Either or both of these type
I muscle flaps can be raised by a sur-
geon with a basic understanding of
the anatomy of the posterior com-
partment of the leg.
Although the gastrocnemius is the
largest muscle of the posterior leg
compartment, the actual size of the
muscle varies greatly depending on
the patient’s habitus. The surgeon
must try to determine preopera-
tively if the bulk of gastrocnemius
muscle is adequate to cover the
wound defect. In a young trauma
patient the muscle is usually well
developed. However, in the elderly
patient who has undergone total
knee arthroplasty and who has a

wound dehiscence, it may be quite
small. If the patient has well-devel-
oped calves and muscular legs, a
large gastrocnemius muscle will be
present. If the patient has long, thin
legs or is malnourished with poor
muscle development, the muscle
will have little bulk and will supply
poor coverage. The bulk of the
transferred gastrocnemius muscle is
occasionally a source of cosmetic
complaint by patients.
A musculocutaneous gastrocne-
mius flap can be used to increase
flap length. The extended length
adds only cutaneous tissue and
requires a split-thickness skin graft
to close the donor site. The cosmetic
result may be unacceptable due to
the donor-site contour defect. The
musculocutaneous gastrocnemius
flap is not described in this review.
The superficial posterior location
of the muscle allows relative ease of
elevation of the flaps. This location
also protects the muscle from dam-
age in most injuries, since wounds
are more often anterior over the sub-
cutaneous border of the tibia. One
exception is the crushing injury (e.g.,

a bumper injury) in which the poste-
rior muscles have been damaged. In
this situation, the gastrocnemius
muscle may be unfit for local trans-
position, and a free flap may be
required.
Anatomy
The medial and lateral heads of
the gastrocnemius muscle take ori-
gin from their respective femoral
condyles and join just distal to the
knee. The muscle becomes tendi-
nous near the junction of the middle
and distal thirds of the leg and joins
the soleus tendon to form the
Achilles tendon.
The medial head is larger and
longer (3.0 to 4.0 cm) than the lateral
head and is the preferred head of the
gastrocnemius for local transposition
flaps if allowed by the location of the
defect. The medial head is adjacent
to the tibia, allowing the muscle to be
easily transposed over the typical
proximal anterior tibial wound as far
as the lateral border of the patella.
The lateral head is separated from
the tibia by the fibula, the lateral
compartment, and the anterior com-
partment, making the reach to the

tibia longer. Even so, it can easily
reach the lateral border of the patella.
If it is necessary to gain additional
length, the lateral head can be tun-
neled under the lateral and anterior
compartments after a fibulectomy to
decrease the distance to the defect.
This must be done with extreme care
so that the pedicle to the muscle does
not become kinked under the ante-
rior and lateral compartments.
Fibulectomy can lead to other prob-
lems. For example, it may preclude
later reconstructive procedures, such
as fibula-to-tibia grafts to achieve
fracture union.
Because the sural artery is the sin-
gle proximal dominant vascular
pedicle to each head of the muscle,
the gastrocnemius muscle flap is a
type I flap. Each head has a separate
sural artery, which is a branch of the
popliteal artery at the level of the
femoral condyle. Each artery enters
the muscle just beneath the level of
the joint space and arborizes in the
proximal muscle. It supplies the skin
over the muscle and distal to the mus-
cle belly through a fasciocutaneous
circulation. The blood supply is very

reliable unless there has been a knee
dislocation or a significantly dis-
placed supracondylar femoral frac-
ture. These injuries can result in
damage to the sural arteries, render-
ing the gastrocnemius nonviable if
raised on this pedicle. A similar situ-
ation may exist if the patient has had
a femoral popliteal vascular bypass
Vol 2, No 6, Nov/Dec 1994 345
Gary D. Bos, MD, and Mark J. Buehler, MD
Fig. 3 Areas of potential anterior coverage
from medial and lateral gastrocnemius mus-
cle flaps.
because of either trauma or periph-
eral vascular disease. If that is the
case, an arteriogram must be
obtained to document patency of the
sural arteries before a local gastrocne-
mius transposition flap is attempted.
Flap Elevation
Medial Gastrocnemius Muscle Flap
The muscle is exposed using a lon-
gitudinal incision that parallels the
medial border of the tibia.
8
If the
flap is to be tunneled under a skin
bridge, the incision is placed posteri-
orly so that the bipedicle flap created

between the incision and the ante-
rior defect is at least 7 cm in width.
This is necessary to prevent skin
necrosis when this bridge of skin is
raised to allow transposition of the
muscle under the skin bridge and
into the anterior wound (Fig. 4). The
incision extends from the tibial
plateau to 8 to 10 cm above the ankle.
The saphenous vein should be left
attached to the superficial fascia to
maintain maximum venous outflow
from the damaged leg.
The muscle is easily separated
from the overlying subcutaneous tis-
sue and fascia by blunt dissection.
The plane between the soleus and
the medial head of gastrocnemius is
developed with finger dissection.
The location of the few small vessels
in this interval should be noted
before they are carefully coagulated,
since they may help define the loca-
tion of the median raphe.
The medial head is then separated
from the lateral head by identifying
the raphe between them. This raphe
is difficult to see in well-developed
individuals, but there are other clues
to the proper line of separation. On

the superficial posterior surface of
the gastrocnemius muscle, the inter-
val is defined by the sural nerve. On
the deep surface of the gastrocne-
mius, multiple small vessels connect
the soleus to the gastrocnemius in a
longitudinal fashion along the
raphe. This anatomic feature helps
define the interval. Proximally, the
raphe may be defined by careful fin-
ger dissection into the popliteal
fossa where the two heads separate.
The attachment of the medial head
to the Achilles tendon is sharply
released, leaving a small amount of
tendon still attached to the muscle
for later suture placement. The two
heads are then separated using
sharp and blunt dissection. As the
dissection approaches the knee joint,
finger dissection is preferred to
avoid damage to the sural vessels.
The bridge of skin and subcutaneous
tissue separating the traumatic
wound and the incision is raised,
making sure that there is adequate
space to avoid pressure on the trans-
posed muscle.
If the width of the flap is inade-
quate, the deep fascia of the muscle

can be removed or incised longitudi-
nally to allow the muscle to spread
out and cover more area. The small
amount of tendon on the distal end of
the muscle is used to set the flap into
the defect. If the medial head does
not reach the wound, it can be further
mobilized by releasing the muscle
from its origin on the medial femoral
condyle, taking care to preserve the
vascular pedicle, which enters the
muscle about 3 cm above the joint
line. The flap can be inverted if nec-
essary for better coverage or contour.
It is then grafted with a meshed split-
thickness skin graft. If the exposed
fascia on the flap is thick, it can be
carefully stripped from the flap, or
multiple small incisions can be made
in the fascia (“pie-crusting”) for bet-
ter take of the skin graft. Wounds are
closed over suction drains.
Lateral Gastrocnemius Muscle Flap
To mobilize the lateral head, a lon-
gitudinal incision is made 2 or 3 cm
posterior to the fibula. The incision
may have to be placed more posteri-
orly to allow for an adequate width
of skin between the anterolateral
defect and the posterolateral longi-

tudinal incision if a tunnel is to be
used. The peroneal nerve is identi-
fied at the neck of the fibula and is
protected throughout the dissection.
The skin is separated from the mus-
cle, and the lateral head is separated
from the medial as previously
described. The muscle is then trans-
posed into position, often under the
mobilized bridge of skin. The per-
oneal nerve is again checked to
avoid possible tension on the nerve
by the transposed muscle. The mus-
cle is skin-grafted, and the wound is
closed as previously described.
Soleus Muscle Flap
The soleus muscle flap is second
only to the gastrocnemius flap as a
local flap for soft-tissue coverage of
346 Journal of the American Academy of Orthopaedic Surgeons
Lower-Extremity Local Flaps
Fig. 4 Completed medial gastrocnemius
flap performed by using a subcutaneous tun-
nel with a minimum of 7 cm between the
incision and the defect. Flap area is shaded.
the tibia. This type II flap is the pre-
ferred local flap for coverage of the
middle third of the tibia (Fig. 5). The
soleus is expendable, especially
when transferred as a “hemisoleus,”

and harvest leaves a very subtle
donor-site deformity.
9
However,
this flap is more difficult to raise
than the gastrocnemius flap because
attention must be paid to the adja-
cent posterior tibial neurovascular
bundle. A significant disadvantage
of the soleus flap is that circulation
to the distal end of the flap is unreli-
able. This is especially true in the
case of a high-energy fracture.
Although the soleus occupies the
posterior compartment of the leg
with the gastrocnemius, it is affected
differently in many open fractures.
Since the soleus is closely adherent to
the deep posterior surface of the
interosseous membrane and the tibia
and fibula, it is often damaged in
open high-energy or crush fractures
of the tibia. The resultant muscle
injury is often severe enough to pre-
clude its use as a transposition flap.
Judgment is key in selecting reli-
able soleus transposition flaps. If the
preoperative evaluation shows a
great deal of ecchymosis and swelling
in the posterior compartment and

there is gross instability of the frac-
ture, one can assume significant frac-
ture displacement and damage to the
soleus. If the initial radiographs,
especially the lateral view, show gross
displacement of the fracture, poste-
rior-compartment muscle damage is
likely. During the initial debridement
of the wound, digital exploration will
occasionally reveal penetration of the
soleus by the fractured tibia, making
the muscle unsuitable for transposi-
tion. In these situations, free-tissue
transfer is a better choice for middle-
third tibial coverage.
Anatomy
The soleus is a muscle of the
superficial posterior compartment
of the leg and is located deep to the
gastrocnemius muscle. It extends
the entire length and width of the
leg. Unlike the gastrocnemius,
which has no direct origin on the
tibia, the soleus originates from the
posterior surface of the tibia, the
interosseous membrane, and the
proximal third of the fibula. The
muscle joins with the gastrocnemius
and inserts into the calcaneus. In the
proximal third of the leg, it is cov-

ered by the belly of the gastrocne-
mius; in the middle third, it is
located beneath the tendon of the
gastrocnemius; and in the distal
third, it blends with the tendon of
the gastrocnemius.
The soleus is a bipenniform muscle.
The medial head originates from the
posterior surface of the tibia. The lat-
eral head originates from the proxi-
mal fibula. The medial and lateral
heads are fused proximally, and in
their distal half they are separated by
a well-defined septum before they
fuse with the gastrocnemius tendon.
The soleus is considered to have a
type II pattern of blood supply, with
the popliteal, posterior tibial, and per-
oneal arteries giving dominant
branches to the proximal third of the
two heads of the muscle. The lateral
head receives most of its blood supply
from the peroneal artery. The distal
two thirds of the muscle receives minor
pedicles from the posterior tibial artery
(PTA). These branches must be sev-
ered before flap rotation, and their loss
may account for the occasional under-
perfusion of the distal portion of the
flap. The surgeon must closely observe

the distal flap circulation before the flap
is sutured into position.
8
Flap Elevation
Under tourniquet control, the
soleus is harvested by means of a
medial approach through a longitudi-
nal incision paralleling the border of
the tibia and extending from just
beneath the tibial plateau to just above
the medial malleolus. If possible, this
incision should incorporate the trau-
matic wound to avoid creating a skin
bridge. Either a hemisoleus or a total
soleus flap can be elevated, depending
on the size of the traumatic defect and
the size of the soleus. If a medial
hemisoleus flap is raised, one must
split the soleus lateral to the midline to
capture the intermuscular artery,
which runs down the center of the
muscle. This will increase the likeli-
hood of survival of the entire muscle.
If, for some uncommon reason,
the lateral approach is used to har-
vest a soleus flap, the surgeon must
be aware that the fibula will limit the
arc of rotation. This can be corrected
somewhat by removal of the fibula,
but it must be accepted that this

could lead to problems with late
reconstruction of a tibial nonunion.
Ordinarily, the soleus is identified in
the proximal third of the leg, where it
lies between the gastrocnemius muscle
and the deep transverse fascia. The
posterior tibial neurovascular bundle
is identified and protected. After the
muscle has been cleared on both its
deep and its superficial surface, it is
separated from the Achilles tendon.
The width of the harvested muscle is
Vol 2, No 6, Nov/Dec 1994 347
Gary D. Bos, MD, and Mark J. Buehler, MD
Fig. 5 Areas of potential anterior coverage
from medial and lateral transposition of the
soleus muscle. Transposition around the lat-
eral side is seldom used.
dictated by the defect. Distal small
perforators from the posterior tibial
vessels are ligated and divided as nec-
essary to allow flap rotation. The flap
is rotated into the defect and inset. It is
then covered with a meshed split-
thickness skin graft, and the incision is
closed in standard fashion, using a
drain if necessary.
Posterior Tibial Artery
Fasciocutaneous Flap
Prior to the introduction of local

transposition muscle flaps and
microvascular free-tissue transfers,
random cutaneous flaps were
attempted for soft-tissue coverage in
the leg with mixed success. In 1981,
Pontén
10
pointed out the signifi-
cance of the fasciocutaneous circula-
tion. Subsequently, the vascular
anatomy of the skin was closely
detailed.
11
Fasciocutaneous flaps
were designed with more pre-
dictable circulation, and acceptable
results were reported.
12,13
There are some disadvantages to
the fasciocutaneous flap. Unlike mus-
cle flaps, the fasciocutaneous flap has
minimal bulk and cannot be used to
obliterate dead space in a wound. The
skin flap has less blood supply than a
muscle flap, which decreases its abil-
ity to resist the contamination often
seen in these defects. If the flap is not
carefully designed, tip necrosis may
result, compromising coverage of the
defect. Many high-energy and crush-

ing injuries damage the fasciocuta-
neous envelope to a degree that
contraindicates its use. Patients with
diabetes mellitus or peripheral vascu-
lar disease and elderly patients are
generally not candidates for fasciocu-
taneous flaps.
In spite of these disadvantages,
the PTA fasciocutaneous flap may be
successfully applied to some small
middle-third and distal-third tibial
soft-tissue defects (Fig. 6), provided
the defect is at least 10 cm from the
ankle. The flap is easy to raise if the
principles of fasciocutaneous circu-
lation are applied. Open fractures
associated with low-energy injuries
and minimal muscle or bone loss are
ideal indications. These situations
are uncommon but are sometimes
seen in fractures associated with an
abrasive action. An example is
trauma due to striking the leg on the
dashboard in a motor-vehicle acci-
dent and avulsing the pretibial skin,
with or without associated tibial
fracture. This is a low-energy injury
with exposed bone, but the sur-
rounding fasciocutaneous envelope
is in good condition, allowing for a

local fasciocutaneous transposition
flap. The PTA fasciocutaneous flap
can be rotated farther than the com-
monly used bipedicle (“relaxing
incision”) flap in this situation.
Anatomy
The fasciocutaneous perforators
of the posteromedial aspect of the
leg arise from the PTA. Arterial and
venous perforators from the PTA
course to the skin through the crural
septum between the deep and
superficial muscle compartments of
the posterior portion of the leg. The
skin flap is dependent on these sep-
tal perforators for survival. The PTA
gives off a series of five or six perfo-
rators, which emerge in the crural
septum between the soleus and the
flexor digitorum longus muscle.
They perforate the fascia and con-
nect to a plexus at the level of the
deep fascia. The lowest perforators
are 5 to 7 cm above the malleolus.
Flap Elevation
The flap design is dictated by the
defect. Usually, a tongue-shaped
flap is fashioned with the flap based
proximally and with a maximum
length-width ratio of 3:1. The saphe-

nous vein is always included in the
flap to aid in venous outflow (Fig. 7).
The posterior incision is made in
such a fashion as to avoid exposure
of the Achilles tendon after transpo-
sition. The distal portion of the flap
should not extend closer to the
malleolus than 2 or 3 cm. After rota-
tion, the flap will not cover defects
closer to the ankle than 10 cm. The
incisions are carried through the
skin, fat, and deep fascia. Sutures
348 Journal of the American Academy of Orthopaedic Surgeons
Lower-Extremity Local Flaps
Fig. 6 Area of potential anterior coverage
with a PTA fasciocutaneous flap.
Fig. 7 Outline of a typical PTA fasciocuta-
neous flap. The long saphenous vein is
divided at the distal end of the flap and
transposed with the flap. Flap area is
shaded.
are placed in the flap to prevent
shearing between the skin and the
fascia during manipulation.
Once the skin and fascia have
been incised, the posterior aspect
of the flap can be elevated with fin-
ger dissection because only loose
alveolar tissue connects the fascio-
cutaneous flap to the muscles pos-

teriorly. The septum between the
deep and superficial compart-
ments of the leg tethers the flap at
this point and must be released to
allow adequate mobility of the
flap. Since this septum contains
the septal perforators, it must be
released judiciously to allow ade-
quate release for wound coverage.
Occasionally, the perforators can
be visualized in the septum and
can be spared by releasing the fas-
cia without cutting the vessels.
The flap is then transposed over
the bone, and the resultant defect in
the posteromedial portion of the leg
is closed with a meshed split-thick-
ness skin graft. Any unsightly dog-
ear created by rotation of the flap
should be revised after healing is
complete to avoid vascular compro-
mise to the flap.
Dorsalis Pedis Island Flap
Many skin flaps that were once
thought to have direct axial blood
supply are now thought to be sup-
plied by the fasciocutaneous system.
However, the dorsalis pedis island
flap remains an example of a direct
axial flap. Careful attention to detail

is required to successfully raise this
skin flap, which relies on a single
inflow artery. This is a good local
flap for coverage of ankle and hind-
foot skin defects (Fig. 8),
14,15
but it is
the most technically demanding of
the flaps discussed in this review.
Care must be taken to achieve good
donor-site coverage with a skin graft
because of the location on the dor-
sum of the foot.
Anatomy
The anterior tibial artery supplies
the dorsum of the foot as it crosses
the ankle and continues as the dor-
salis pedis artery. Venous outflow
from this flap is via the venae comi-
tantes and the long saphenous vein.
The dorsalis pedis artery runs along
the tarsus to the first intermetatarsal
space, where it gives off a branch to
the plantar surface and then contin-
ues as a nondominant supply to the
first and second toes (Fig. 9). The
cutaneous branches of the dorsalis
pedis artery enter the skin in a fairly
small strip extending from the exten-
sor retinaculum to a point halfway

along the first interosseous space.
Beyond this point the skin is sup-
plied by the first dorsal metatarsal
artery (FDMA), a continuation of the
dorsalis pedis artery, which lies
beneath the tendon of the extensor
hallucis brevis muscle.
The origin of the FDMA is crucial
to the supply of the distal part of the
flap. In as many as 20% of patients,
the FDMA has a plantar origin
instead of arising from the dorsalis
pedis artery. This precludes its use
in a local rotation flap, since the arc
of rotation is significantly shortened.
Also, in the older patient the dorsalis
pedis artery can be atherosclerotic,
which is another contraindication to
use of this flap. In most cases an
arteriogram should be obtained pre-
operatively to evaluate these poten-
tial problems and to ensure that the
PTA is patent into the foot.
Flap Elevation
The shape of the flap is dictated by
the defect, although some guidelines
are helpful.
16
Most of the vascular-
ization of the flap comes from the

proximal portion of the FDMA. The
design of the flap should be such
that the central portion overlies this
area when possible. A venous
tourniquet should be placed on the
leg prior to dissection to mark the
long saphenous vein and the dor-
salis pedis artery. This will allow
easy incorporation of the long
saphenous vein into the flap. The
dorsalis pedis artery should be used
as the axis of the flap.
The proximal margin of the flap is
at the lower border of the extensor
retinaculum. The flap can extend
across the width of the dorsum of the
foot but should not pass around the
borders of the foot. Distally, the inci-
sion is made proximal to the web
spaces of the toes. Much of the blood
supply to the distal part of the flap
comes from the FDMA, and the vari-
able arrangement of this vessel may
determine the tendency for marginal
necrosis at the distal end. For this
reason, the flap is seldom larger than
10 × 10 cm.
After the flap design has been
drawn on the dorsum of the foot,
using the dorsalis pedis artery as the

axis, and the long saphenous vein has
been included, the venous tourniquet
is released. The distal incision is made
first so that the FDMA can be identi-
fied. If it is not present or is deep and
atrophic, the procedure should be
aborted, and free-tissue transfer
should be elected. It is important to
develop a plane that leaves sufficient
peritenon for take of the split-thick-
ness skin graft on the extensor ten-
dons. This step is very important
because incomplete take of the split-
thickness skin graft on the tendons is
the major complication with this flap.
Vol 2, No 6, Nov/Dec 1994 349
Gary D. Bos, MD, and Mark J. Buehler, MD
Fig. 8 Areas of potential coverage from the
dorsalis pedis island flap.
350 Journal of the American Academy of Orthopaedic Surgeons
Lower-Extremity Local Flaps
The distal end of the flap is then
raised, and the FDMA is identified,
divided, and sutured to the distal
edge of the flap to prevent shearing
between the flap and the vessels,
which would cause devasculariza-
tion. At this point, the flap must be
checked for adequate perfusion. If
the distal part of the proposed flap is

dusky, the incision should be closed,
and a free flap should be selected to
fill the defect. If vascularity is intact,
the incision is extended up the medial
border of the flap, with care being
taken not to damage the long saphe-
nous vein but to take it with the flap.
As the medial edge of the flap is
raised, the tendon of the extensor
hallucis longus will be noted. The
dissection is continued superficial
to this tendon. The vessels are then
raised with the flap from distal and
lateral to proximal and medial,
always watching the vessels to
make sure that they are included
with the flap. The extensor hallucis
brevis tendon must be divided to
raise the flap, since the vessel runs
deep to the tendon (Fig. 9). The
plantar communicating artery will
be encountered between the bases
of the first and second metatarsals;
this must be ligated to raise the
flap. The proximal skin incision is
made, and mobilization of the flap
is completed.
A more proximal longitudinal
incision may be necessary to mobi-
lize more of the vessel, extending the

length of the pedicle. To accomplish
this, the extensor retinaculum is cut,
and the extensor tendons are
retracted, exposing the dorsalis pedis
artery and the anterior tibial vessels.
During the dissection, the exposed
extensor tendons must be kept moist
to avoid damage to the peritenon,
which might compromise take of the
skin graft. The flap is sutured into
position, and a minimally meshed
split-thickness skin graft is placed on
the donor site. The pedicle must be
inspected again to make sure that
kinking did not occur. The foot is
dressed with a bolster and is
splinted for at least 2 weeks to maxi-
mize incorporation of the skin graft.
Summary
Of the five lower-extremity local
flaps discussed, the gastrocnemius
flap is used most often because it
covers wounds at the knee and prox-
imal tibia, which are the common
sites of defects. This flap is relatively
easy to use and has predictably good
results. The TFL and PTA fasciocu-
taneous flaps are also easy to use if
the vascular anatomy is respected,
but there are relatively few

orthopaedic indications for these
flaps. The soleus and dorsalis pedis
flaps are the most technically
demanding of the five flaps. The
contraindications and caveats men-
tioned must be observed for the
flaps to be successful. Fortunately,
free-flap techniques and more com-
plex local flaps are available in most
situations if the described local flaps
will not work, as is the case in the
area proximal to the ankle and in
many areas on the foot.
Fig. 9 Anatomic details of the dorsalis pedis artery and its extension as the first dorsal
metatarsal artery.
Vol 2, No 6, Nov/Dec 1994 351
Gary D. Bos, MD, and Mark J. Buehler, MD
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